Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynaecologists and Obstetricians (CNGOF)

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding (i.e. pharmaceutical or medical device companies). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège National des Gynécologues et Obstétriciens Français on the management of women with AUB were published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescents; idiopathic AUB; endometrial hyperplasia and polyps; type 0-2 fibroids; type 3 or higher fibroids; and adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and evidence profiles were compiled. The GRADE® methodology was applied to the literature review and the formulation of recommendations.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 are strong and 17 weak. No response was found in the literature for 14 questions. We chose to abstain from recommendations rather than providing advice based solely on expert clinical experience.

CONCLUSIONS

The 36 recommendations make it possible to specify the diagnostic and therapeutic strategies for various clinical situations practitioners encounter, from the simplest to the most complex.

[Management of women with abnormal uterine bleeding: Clinical practice guidelines of the French National College of Gynecologists and Obstetricians (CNGOF)]

OBJECTIVE

To provide French guidelines for the management of women with abnormal uterine bleeding (AUB).

DESIGN

A consensus committee of 26 experts was formed. A formal conflict-of-interest (COI) policy was developed at the beginning of the process and enforced throughout. The entire guidelines process was conducted independently of any industrial funding (i.e. pharmaceutical, or medical devices). The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The last guidelines from the Collège national des gynécologues et obstétriciens français (CNGOF) on the management of women with AUB was published in 2008. The literature seems now sufficient for an update. The committee studied questions within 7 fields (diagnosis; adolescent; idiopathic AUB; endometrial hyperplasia and polyps; fibroids type 0 to 2; fibroids type 3 and more; adenomyosis). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 36 recommendations. Among the formalized recommendations, 19 present a strong agreement and 17 a weak agreement. Fourteen questions did not find any response in the literature. We preferred to abstain from recommending instead of providing expert advice.

CONCLUSIONS

The 36 recommendations made it possible to specify the diagnostic and therapeutic strategies of various clinical situations managed by the practitioner, from the simplest to the most complex.

Ergotism with acute limb ischemia, provoked by HIV protease inhibitors interaction with ergotamine, rescued by multisite transluminal balloon angioplasty

Acute limb ischemia induced by arterial vasospasm remains an exceptional situation, favoured by the use of arterial vasoconstrictors. The risk of these substances is largely underestimated in the general population, especially with the co-administration of strong cytochrome inhibitors like human immunodeficiency virus (HIV) protease inhibitors. A 33-year-old woman, who used to take dihydroergotamine for orthostatic hypotension, was prescribed a post-exposure HIV prophylaxis including lopinavir and ritonavir. One day later, she presented an acute bilateral limb ischemia with a sudden pain in both calves, initially while walking and then at rest with bilateral ischemic toes. Angiography confirmed diffuse arterial vasospasm of the lower limb arteries. A first-line therapy with isosorbide dinitrate and amlodipine was ineffective, with rapid clinical worsening. A combination of intra-arterial injections and intra-venous infusions of vasodilators, transluminal balloon angioplasty and bilateral 4-Compartment fasciotomies permitted rapid improvement and finally resulted in both lower limbs rescue. This case and literature review illustrate ergotism due to ergotamine overdose after taking HIV protease inhibitors. It also demonstrates the benefit of an interventional procedure besides medical therapy with vasodilators in severe arterial vasospasm. All along the lower limb arterial tree, transluminal balloon angioplasty restored the blood flow, without vasospasm recurrence. CONCLUSION: In case of ergotism with acute lower limbs ischemia, combining medical vasodilator therapy with interventional procedure can restore the arterial blood flow, thus allowing to save lower limbs.

Clinic Versus Ambulatory Blood Pressure in Resistant Hypertension: Impact of Antihypertensive Medication Nonadherence

Clinic-ambulatory blood pressure (BP) difference is influenced by patients- and device-related factors and inadequate clinic-BP measurement. We investigated whether nonadherence to antihypertensive medications may also influence this difference in a post hoc analysis of the DENERHTN trial (Renal Denervation for Hypertension). We pooled the data of 77 out of 106 evaluable patients with apparent resistant hypertension who received a standardized antihypertensive treatment and had both ambulatory BP and drug-screening results available at baseline after 1 month of standardized triple therapy and at 6 months on a median of 5 antihypertensive drugs. After drug assay samplings on study visits, patients took their antihypertensive treatment under supervision immediately after the start of the ambulatory BP recording, and supine clinic BP was measured 24 hours post-dosing; both allowed to calculate the clinic minus daytime ambulatory systolic BP (SBP) difference (clinic-SBP–day-SBP). A total of 29 (37.7%) were found nonadherent to medications at baseline and 38 (49.4%) at 6 months. At baseline, the mean clinic-SBP–day-SBP difference in the nonadherent group was 12.7 mm Hg (95% CI, 7.8–17.7 mm Hg, P <0.001). In contrast, clinic SBP was almost identical to day-SBP in the adherent group (clinic-SBP–day-SBP difference, 0.1 mm Hg; 95% CI, −3.3 to 3.5 mm Hg; P =0.947). Similar observations were made at 6 months. Using receiver operating characteristics curves, we found that a 6 mm Hg cutoff of clinic-SBP–day-SBP difference had 67% sensitivity and 69% specificity to predict nonadherence to the triple therapy at baseline. In conclusion, a large clinic-SBP–day-SBP difference may help discriminating between adherence and nonadherence to treatment in patients with resistant hypertension.

Clinical Trial Registration—

URL: https://www.clinicaltrials.gov . Unique identifier: NCT01570777.

Correction to: Percutaneous Deep Venous Arterialization for Severe Critical Limb Ischemia in Patients With No Option of Revascularization: Early Experience From Two European Centers

The fifth author's name was incorrectly published as "M. Messas". The correct name is "E. Messas". The original article has been corrected.

[Recanalization procedure of the common femoral vein following iatrogenic femoral chronic occlusion: 3 cases]

Common femoral vein occlusion (CFVO) is frequently found in patients with chronic venous insufficiency. The iatrogenic form, secondary to either central catheter or surgery, is very rare but highly symptomatic. Classical compression therapy barely improves the clinical status of these patients, making them suitable candidates for an interventional procedure for venous recanalization.

METHODS

We report here three consecutive cases of iatrogenic CFVO referred to our outpatient clinic because the disease had an impact on daily life activities. We detail the recanalization procedure, the Doppler control and the short-term outcome.

RESULTS

In each case, endovascular recanalization required rigid material (rigid guide or Colapinto needle) to cross the fibrous adhesions before angioplasty could be performed with stenting. The procedure required two attempts in each case, underlining its complexity, but eventually enabled effective recanalization. No major complication occurred per- or post-procedure. One month later, a duplex Doppler control confirmed the permeability of the common femoral vein. The patients had experienced rapid and significant symptom improvement.

CONCLUSION

Patients suffering from severe chronic venous insufficiency caused by iatrogenic CFVO can benefit from endovascular recanalization. Although these procedures may be complex due to the extensive fibrosis at the Scarpa and require specialized equipment, no major complications were observed. Patency of the recanalization persisted at least one month after the procedure. Symptom relief was good.

Percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma under C-arm cone beam CT guidance

PURPOSE

The aim of this study was to assess the feasibility, safety and efficacy of percutaneous radiofrequency ablation of lung metastases from colorectal carcinoma using C-arm cone beam computed tomography (CBCT) guidance.

MATERIAL AND METHODS

This single-center prospective observational study was performed from August 2013 to August 2016, and included consecutive patients referred for radiofrequency ablation of lung metastases from colorectal cancer. Radiofrequency ablation procedures were performed under C-arm CBCT guidance. Feasibility was assessed by probe accuracy placement, time to accurate placement and number of C-arm CBCT acquisitions to reach the target lesion. Safety was assessed by the report of adverse event graded using the common terminology criteria for adverse events (CTCAE-V4.0). Efficacy was assessed by metastases response rate using RECIST 1.1 and ¹⁸FDG-PET-CT tumor uptake at 6months.

RESULTS

Fifty-four consecutive patients (32 men, 22 women) with a mean age of 63±8 (SD) years (range: 51-81years) with a total of 56 lung metastasis from colorectal metastases were treated in a single session. The mean tumor diameter was 25.6±4.5 (SD)mm (range: 17-31mm). Median time to insert the needle into the target lesion was 10min (range: 5-25min). Median number of needles repositioning and C-arm CBCT acquisition per patient was 1 (range: 0-3) and 4 (range: 3-6) respectively. The accuracy for radiofrequency ablation probe placement was 2±0.2 (SD)mm (range: 0-9mm). Pneumothorax requiring chest tube placement occurred in one patient (CTCAE-V4.0 grade 3). At 6months, all patients were alive with tumor response rate of -27% and had no significant activity on the ¹⁸FDG-PET CT follow-up.

CONCLUSION

Percutaneous radiofrequency ablation of lung metastases from colorectal cancer under C-arm CBCT guidance is feasible and safe, with immediate and short-term results similar to those obtained using conventional CT guidance.

Embolization of the superior rectal arteries for chronic bleeding due to haemorrhoidal disease

AIM

The aim of this study was to assess the safety and efficacy of the emborrhoid technique (embolization of the superior haemorrhoidal arteries) in patients ineligible for surgery.

METHODS

Between January 2014 and April 2015, 30 consecutive patients (average age 58 years) suffering from disabling chronic bleeding due to haemorrhoidal disease and with a contraindication for surgery (n = 23) or with a failure of instrumental or surgical treatment (n = 7) underwent embolization. All cases were discussed at multidisciplinary meetings including a proctology specialist or a surgeon and an interventional radiologist. We performed super selective micro coil embolization (pushable 2-3 mm fibre coils) of the distal branches of the superior rectal arteries with a microcatheter, via a right femoral approach, under local anaesthesia. We assessed clinical outcome by evaluating bleeding and specific clinical scores relating to bleeding and changes in quality of life.

RESULTS

Immediate technical success, with no complication, was achieved in 93% of cases. A mean of 3.1 arteries per patient was embolized, with a mean of 7.6 coils per patient. Median follow-up was 5 months. Clinical score improvement was observed in 72%, in 17 patients after a single embolization session, and in four additional patients after a second embolization session. No improvement in bleeding was observed in eight patients (28%).

CONCLUSION

Distal coil embolization of the superior rectal arteries for disabling chronic bleeding due to haemorrhoidal disease is safe and effective in patients untreatable by surgery.

Safety and efficacy of superior rectal artery embolization with particles and metallic coils for the treatment of hemorrhoids (Emborrhoid technique)

PURPOSE

The purpose of this study was to comprehensively evaluate the short-term outcomes after percutaneous embolization of the superior rectal artery (SRA) with metallic coils and particles for the management of hemorrhoids.

MATERIALS AND METHODS

Forty patients (15 men, 25 women) with a mean age of 35±5 years (SD) (range: 25-65 years) were prospectively enrolled. All patients had symptomatic hemorrhoids. The distribution of internal hemorrhoids was as follows: grade I (n=6, 16%); grade II (n=28, 69%) and grade III (n=6; 15%). All patients had percutaneous embolization of the SRA with metallic coils and synthetic polyvinyl alcohol particles. Follow-up evaluation included clinical examination, rectoscopy, histopathological analysis of rectal mucosa, duplex Doppler blood flow quantification, electromyography, sphincterometry of the anal sphincter and analysis of patient satisfaction.

RESULTS

No immediate complications were observed and no patients had anal pain syndrome after embolization. Hemorrhoids showed a 43% size reduction after embolization (P<0.05). Taking into account the symptom resolutions such as irritation, discomfort, bloody discharge and pain, satisfaction was observed in 5/6 (83%) patients with grade III hemorrhoids and 32/34 patients (94%) with grades I-II hemorrhoids. One month after embolization, anal sphincter contractility normalized and no changes in anal electromyography were observed. Blood flow in the hemorrhoidal plexus dropped from 109±1.2ml/min/100g (SD) before treatment to 60.2±4.4ml/min/100g (SD) (P<0.05) the day after embolization and remained unchanged one month after embolization.

CONCLUSION

Our study demonstrates that embolization of SRA with particle and coils does not lead to ischemia in patients with symptomatic hemorrhoids. Short-term results with regard to symptom management for hemorrhoidal disease are very encouraging and should stimulate further prospective and multicenter studies.

Spontaneous soft tissue hematomas

Spontaneous muscle hematomas are a common and serious complication of anticoagulant treatment. The incidence of this event has increased along with the rise in the number of patients receiving anticoagulants. Radiological management is both diagnostic and interventional. Computed tomography angiography (CTA) is the main tool for the detection of hemorrhage to obtain a positive, topographic diagnosis and determine the severity. Detection of an active leak of contrast material during the arterial or venous phase is an indication for the use of arterial embolization. In addition, the interventional radiological procedure can be planned with CTA. Arterial embolization of the pedicles that are the source of the bleeding is an effective technique. The rate of technical and clinical success is 90% and 86%, respectively.

[Distal revascularization in diabetic patients with chronic limb ischemia]

Diabetes mellitus is an independent risk factor for peripheral artery disease. Life expectancy is 41 months for diabetic patients with an ischemic ulcer. The characteristics of diabetic arteriopathy make its treatment more difficult than in non-diabetic patients. Few data are available about the surgical treatment of arteriopathy in diabetic patients (including angioplasty or bypass), especially in case of distal arteriopathy. The choice of the procedure depends on multiple factors such as the disease localization, its extent, distal blood flow and vascular disease-related surgical risk. The principal aim of revascularisation is to restore direct flow to the foot in order to ensure wound healing and limb salvage. With percutaneous endoluminal angioplasty, limb salvage can be achieved in more than 80% of patients at 1-3 years. The percutaneous procedure is less invasive than open surgery, there are fewer complications, and morbidity and mortality rates are reduced; moreover, a second procedure remains possible in the future. With bypass surgery, the rate of limb salvage exceeds 80% at five years. Nevertheless, peri-operative mortality reaches 3% and arterial anatomy, patient-related risks factors or venous graft availability may be limitations. New endovascular techniques especially designed for the distal arteries of the lower limbs enable very distal revascularization with morbidity and mortality rates lower than with surgery.

Emborrhoid: a new concept for the treatment of hemorrhoids with arterial embolization: the first 14 cases

PURPOSE

The 'emborrhoid' technique consists of the embolization of the hemorrhoidal arteries. The endovascular arterial occlusion is performed using coils placed in the terminal branches of the superior rectal arteries. The emborrhoid technique has been modeled after elective transanal Doppler-guided hemorrhoidal artery ligation which has been shown to be effective in hemorrhoidal disease. We report the first 14 cases of our experience with emborrhoid technique.

MATERIALS AND METHODS

Fourteen patients with disabling chronic rectal bleeding were treated using the emborrhoid technique (3 women, 11 men). The stage of the hemorrhoidal disease was II (10 patients), III (3), and IV (1). This treatment was decided by a multidisciplinary team (proctologist, visceral surgeon, and radiologist). Seven patients underwent previous proctological surgery. Ten patients had coagulation disorders (anticoagulants or cirrhosis). Superior rectal arteries were embolized with pushable microcoils (0.018).

RESULTS

Technical success of the embolization procedure was 100 %. Clinical success at 1 month was 72 % (10/14). Of the 4 patients who experienced rebleeding, two underwent additional embolization of the posterior rectal arteries with success. No pain or ischemic complications were observed in 13 patients. One patient experienced a temporary painful and edematous, perianal reaction.

CONCLUSION

Our case studies suggest that coil embolization of the superior rectal arteries is technically feasible, safe and well tolerated. Additional studies are needed to evaluate the efficacy of this new 'emborrhoid' technique in the management of hemorrhoidal disease.

Endovascular treatment for post-thrombotic syndrome. Two case studies and a literature review

The recent application of endovascular treatment techniques to venous pathologies has meant that new therapeutic solutions can be offered to patients suffering from post-thrombotic syndrome. This often-underestimated condition frequently complicates cases of deep vein thrombosis, whether treated or not, leading to a chronic and disabling set of clinical symptoms (oedema, claudication, pain, venous ulcers, etc.) due to the combination of the pathophysiological phenomena of obstructions and reflux. These clinical signs see only minimal improvement when managed with the classic medical treatment, venotonic agents, and venous compression. We report the cases of two patients suffering with chronic post-thrombotic venous obstruction of the lower limbs in whom endovascular treatment brought clear and long-lasting clinical improvement.

Catheter-based radiofrequency renal-nerve ablation in patients with resistant hypertension

This review aims to describe the role and the results of catheter-based renal nerve ablation for the treatment of resistant hypertension. Despite the availability of multiple classes of orally active antihypertensive treatments, resistant hypertension remains an important public health issue in 2012 due to its prevalence and association with target-organ damage and poor prognosis. The failure of purely pharmacological approaches to treat resistant hypertension has stimulated interest in invasive device-based treatments based on old concepts. In the absence of orally active antihypertensive agents, patients with severe and complicated hypertension were widely treated by surgical denervation of the kidney until the 1960s, but this approach was associated with a high incidence of severe adverse events and a high mortality rate. A new catheter system using radiofrequency energy has been developed, allowing an endovascular approach to renal denervation and providing patients with resistant hypertension with a new therapeutic option that is less invasive than surgery and can be performed rapidly under local anaesthesia. To date, this technique has been evaluated only in open-label trials including small numbers of highly selected resistant hypertensive patients with suitable renal artery anatomy. The available evidence suggests a favourable blood pressure-lowering effect in the short term (6 months) and a low incidence of immediate local and endovascular complications. This follow-up period is, however, too short for the detection of rare or late-onset adverse events. For the time being, the benefit/risk ratio of this technique remains to be evaluated, precluding its uncontrolled and widespread use in routine practice.

One year clinical outcomes of renal artery stenting: the results of ODORI Registry

The safety, efficacy and long term clinical benefits of renal artery revascularization by stenting are still a matter of debate. The aim of our study was to define the safety and efficacy of renal artery stenting with the Tsunami peripheral stent (Terumo Corporation, Tokyo, Japan). The ODORI was a prospective, multicentre registry which enrolled 251 consecutive patients, (276 renal arteries) in 36 centres across Europe. The primary endpoint was acute procedural success defined as <30% residual stenosis after stent placement. Secondary endpoints included major adverse events, blood pressure control, serum creatinine level, and target lesion revascularization (TLR) at 6 and 12 months. Patients were 70 +/- 10 years old, 59% were male, 33% had diabetes, and 96% hypertension. The main indications for renal stent implantation were hypertension in 83% and renal salvage in 39%. Direct stent implantation was performed in 76% of the cases. Acute success rate was 100% with residual stenosis of 2.5 +/- 5.4%. Systolic/diastolic blood pressure decreased from a mean of 171/89 at baseline to 142/78 mmHg at 6 months (p < 0.0001 vs. baseline), and 141/80 mmHg at 12 months (p < 0.0001 vs. baseline). Mean serum creatinine concentration did not change significantly in the total population. However, there was significant improvement in the highest tercile (from 283 micromol/l at baseline to 205 and 209 micromol/l at 6 and 12 months respectively). At 12-months, rates of restenosis and TLR were 6.6 and 0.8% respectively. The 12 month cumulative rate of all major clinical adverse events was 6.4% while the rate of device or procedure related events was 2.4%. In hypertensive patients with atherosclerotic renal artery stenosis Tsunami peripheral balloon-expandable stent provides a safe revascularization strategy, with a potential beneficial impact on hypertension control and renal function in the highest risk patients.

[Virtual interventional radiology: evaluation of performances as a function of experience]

PURPOSE

To determine the value of an angioplasty simulation to differentiate the users based on their level of experience. To determine the perceived usefulness of an angioplasty simulation program.

MATERIALS AND METHODS

Forty-six radiologists performed a renal angioplasty on a VIST simulator (Mentice Corporation, Gothenburg, Sweden); the procedure was completed by 41 radiologists. The radiologists were divided into two groups based on the level of experience. Quantitative variables analyzed included procedure duration time and fluoroscopy time. The radiologists then completed a questionnaire evaluating the simulation program.

RESULTS

Radiologists with more than 2 years of clinical experience (n=14) performed the procedures faster (20.4 min vs 27.4 min, p<0.01) using less fluoroscopy time (7.8 min vs 11.2 min, p<0.05) than others. Radiologists performing more than 2 procedures per month (n=14) performed the procedures faster (19.4 min vs 27.9 min, p<0.01) using less fluoroscopy time (7.4 min vs 11.3 min, p<0.05) than other (n=27). The participating radiologists indicated that the simulation was realistic.

CONCLUSION

Procedure duration time and duration of fluoroscopy were criteria able to differentiate the users based on their level of experience. The educational value of the simulation program was perceived as helpful by the users.

Traitement par voie endovasculaire d'un faux anévrisme tuberculeux de l'isthme aortique

INTRODUCTION

Aortic aneurysms are a well known but rare complication of tuberculosis. Their major complication is aneurysmal rupture, unforeseeable and lethal.

EXEGESIS

Chest pain and hemoptoic expectoration revealed a false aneurysm of the aortic isthmus in a 48-year-old man. Endovascular repair with a stent graft was urgently undertaken. Tuberculosis was diagnosed 6 weeks thereafter by the growth of gastric juice cultures and medically treated. Most tuberculous aortic aneurysms are false aneurysms, caused by an adjacent tuberculous focus eroding the aortic wall. They present with pain, bleeding or as para-aortic masses.

CONCLUSION

Tuberculous false aneurysms of the aorta necessitate an early intervention before they rupture. Surgical treatment remains the preferred option but endovascular repair with a stent graft is a therapeutic alternative, to be considered in high-risk surgical patients.

[Carotid Stenting in France after the EVA 3S and SPACE publications]

Angioplasty of stenoses of the carotid bifurcation is a revascularization procedure that is used successfully in many patients. With more than 10 years of experience now, the feasibility of carotid stenting has been demonstrated. Its distribution is highly variable depending on the country, with a mean penetration rate in Europe of 15% of the number of carotid revascularizations. However, the complication rate is highly variable from one series to another and depends on the type of patient treated and the operator's learning curve. The results of the first two randomized studies comparing endarterectomy and carotid stenting, EVA 3S in France and SPACE in Germany, have just been published. The conclusions of these studies only relate to symptomatic patients, who make up a small proportion of revascularized patients. At 30 days, the French study concluded that surgery was better, and the German study showed no advantage to stenting. The analysis of these results compared to other publications should make it possible to best define the current indications for carotid stenting.

A New Porcine Sponge Material for Temporary Embolization: An Experimental Short-Term Pilot Study in Swine

PURPOSE

To evaluate the safety and efficacy of a porcine-derived gelfoam, Curaspon, for the temporary occlusion of the visceral arteries.

METHODS

Curaspon was used for the selective embolization of segmentary hepatic, unilateral polar renal, and single lumbar arteries of 10 pigs under general anesthesia. Sequential angiographic checks were carried out and the pigs killed between 3 days and 2 weeks later. Macroscopic and microscopic studies using standard techniques were used to evaluate the immediate efficacy of embolization, duration of and completeness of recanalization on angiography, macroscopic appearance of target-organ ischemia, and microscopic analysis of inflammatory reaction.

RESULTS

Immediate arterial occlusion was obtained in all cases. Renal arteries showed a total recanalization in 63% of cases on day 7 and 100% on day 14. Total hepatic recanalization was obtained in 100% of animals on day 7. All lumbar arteries were recanalized on day 14. Microscopic analysis in the kidney revealed a mild inflammatory reaction and a progressive lysis of the Curaspon (87% of samples at day 3 showed a persistence of Curaspon and 5% at day 14). In some cases, localized and partial destruction of the arterial wall was visualized. In the liver the same patterns were observed but resolved more completely and more rapidly.

CONCLUSIONS

Curaspon is an efficient material for the temporary occlusion of visceral and parietal arteries in pigs. However, arterial aneurysms were observed and a relationship of these with the material cannot be excluded.

[Critical limb ischaemia: endovascular treatment in diabetic patients?]

Endovascular treatment has an increasing role in the treatment of patients with critical limb ischemia, particularly in diabetic patients with a majority of infrapopliteal lesions. The aim of the procedure is to obtain a "straight-line flow to the foot" by treating all the significant stenoses and short occlusions that impair distal vascularization. Stents are indicated when there is a suboptimal results following balloon angioplasty (recoil or dissection). Restenosis rate after primary stenting for long lesion is high. Angioplasty is a safe and effective procedure, allowing limb salvage rate in a majority of the cases with a low mortality and morbidity rate.

Imagerie des pathologies vasculaires spécifiques

The diagnosis of vascularitis should be proposed when a concentric and regular thickening of the wall of the aorta or one of its branches is observed or when there is late enhancement of the arterial wall, on sites which are usually free from atheromatous lesions and in a young patient. The radiologist must be aware of the associated clinical signs: oral and genital ulcerative lesions in the Behçet syndrome; finger necrosis in a young male smoker in Buerger disease; hip and shoulder arthropathy and headache in a 70 Year old female and Horton disease; pulseless upper limbs and inflammatory syndrome in a young adult for the Takayasu arteritis. The diagnosis of popliteal entrapment or adventitial cyst should be proposed in young patients without atheromatous lesions.

Thrombose veineuse plantaire interne et anticorps anticardiolipine. Cas clinique

We report a case of isolated plantar venous thrombosis in a young female with no recent history of surgery or trauma who complained of spontaneous left talalgia. She was treated with aspirin for a lupus anticoagulant. The diagnosis was established on the basis of color duplex ultrasonography. The patient was given long-term oral anticoagulants in accordance with international recommendations. Veins other than the usually examined regions, such as plantar veins, should be explored in patients with a known thrombophilic condition who present spontaneous talalgia. Presence of an isolated plantar venous thrombus in a patient with no known coagulation abnormality is suggestive of thrombophilic disease.

[Subintimal angioplasty. Technique, results and role in the treatment of peripheral arterial occlusive disease]

Subintimal angioplasty consists in entering the subintimal space proximal to the occlusion, traversing the occlusion creating by angioplasty a subintimal channel exiting downstream in the natural lumen. Major complications rarely occur but compromising important collaterals or run-off vessels may be very deleterious. Subintimal angioplasty is indicated in patients with critical limb ischemia, unfit for anesthesia or in the absence of a suitable venous conduit. This technique is mainly effective in long and tibioperoneal occlusions, a location in which transluminal angioplasty usually fails. Further studies are required to determine the modalities of associated anti-thrombotic treatment and if subintimal angioplasty can be used as primary treatment in critical leg ischemia.

[Hydatid cyst of the heart interventricular septum: multidetector CT scan and MRI findings]

The present case illustrates the value of multidetector CT scan and cardiac MRI for the diagnosis of a hydatid cyst of the interventricular septum of the heart. These new modalities can help both for surgery planning and follow-up.